Provider Demographics
NPI:1790411734
Name:POLO, LAURIE A
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:A
Last Name:POLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4098 RANDALL DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-1614
Mailing Address - Country:US
Mailing Address - Phone:440-759-6156
Mailing Address - Fax:
Practice Address - Street 1:4098 RANDALL DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-1614
Practice Address - Country:US
Practice Address - Phone:440-759-6156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-30
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5213954376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker